Women’s Health – Connecticut Health Investigative Teamhttp://c-hit.org
In-depth Journalism on Issues of Health and SafetySat, 17 Nov 2018 12:58:17 +0000en-UShourly1https://wordpress.org/?v=4.9.8Midwives Could Be Key To Reversing Maternal Mortality Trendshttp://c-hit.org/2018/10/30/midwives-could-be-key-to-reversing-maternal-mortality-trends/
http://c-hit.org/2018/10/30/midwives-could-be-key-to-reversing-maternal-mortality-trends/#respondWed, 31 Oct 2018 02:07:19 +0000http://c-hit.org/?p=334338The Connecticut Childbirth & Women’s Center in Danbury is a 50-minute drive from Evelyn DeGraf’s home in Westchester. Pregnant with her second child, the 37-year-old didn’t hesitate to make the drive—she wanted her birth to be attended by a midwife, not a doctor.

DeGraf believed midwifery care to be more personal and less rushed than that delivered by obstetrics/gynecologists (OB/GYNs). She also knew an OB/GYN would deem her relatively advanced maternal age and previous cesarean section history too high-risk to attempt a VBAC, or vaginal birth after cesarean section.

But she had to drive roughly 35 miles to find a midwife because there aren’t many of them.

Despite the fact that an estimated 85 percent of women are appropriate for midwife care, midwives attend about 11 percent of births in Connecticut, said Holly Kennedy, professor of midwifery at Yale School of Nursing. By contrast, about half of all babies in England are delivered by midwives, according to National Health Services statistics. Kennedy sees a direct correlation between lower use of midwives and higher maternal mortality.

“If you scaled up midwives, you would avert over 80 percent of maternal deaths,” Kennedy said. In Connecticut, there are 211 licensed nurse-midwives, compared to 945 licensed OB/GYNs, according to state Department of Health records. Unlike some other states, which employ midwives who do not require nursing degrees, Connecticut recognizes only nurse-midwives, who hold advanced degrees in nursing and additional training in midwifery.

Babies born to black women are more than twice as likely to die in the first year of life than babies born to white women, and black women are 243 percent more likely than white women to die from pregnancy-related complications, according to the Centers for Disease Control and Prevention.

DeGraf’s second child was born vaginally at Danbury Hospital, assisted by a nurse-midwife employed by the Connecticut Childbirth Center. Her low-intervention delivery is common of births attended by midwives who, statistically, use fewer intervention than physicians during labor and delivery.

Cesarean sections, considered major surgery, carry well-established risks: higher rates of hemorrhage, transfusions, infections, and blood clots—all primary causes of maternal mortality, whose rates increased nationwide (with the exception of California) by 26.6 percent between 2010 and 2014, according to a study supported by The National Center for Biotechnology Information.

Melanie Stengel photo

Caroline Dicolla of Ridgefield, at left, gets some help bundling up her infant daughter, Kohana Domejczyk, from midwife Cathy Parisi after Dicolla’s appointment the Connecticut Childbirth & Women’s Center in Danbury.

Midwives are also linked to higher rates of physiologic birth and fewer adverse neonatal outcomes, according to a nationwide 2018 study, which ranked states by how well midwives are integrated into regional health care systems. Connecticut fell into the bottom third. Experts say the low ranking is due in large part to a lack of access to midwives. Many would-be nurse-midwives never get the chance to train for the position in Connecticut.

“At Yale, I get at least 100 applicants for our [nurse-midwife] program. Most are highly qualified, but I can only accept 25 percent,” said Kennedy, an author of the 2018 study. She explained that most federal health education dollars are directed to schools of medicine, thereby limiting resources for midwifery education, including the ability to reimburse preceptors who oversee clinical training of nurse-midwife students.

Those who do find spots in one of Connecticut’s two nurse-midwife programs (Fairfield University offers a doctor of nursing practice in midwifery) may confront challenges to practicing upon graduation. Many face high debt hurdles, Kennedy says, and search the country for employers willing to repay their student loans. Those who do find jobs in Connecticut may be stymied from practicing to the fullest extent possible.

Cathy Parisi is director at the Connecticut Childbirth & Women’s Center, the state’s only freestanding birth center. She says that while Connecticut legislation authorizes its nurse-midwives to practice to “full scope care,” which includes admitting privileges at hospitals that credential nurse-midwives, not all hospital bylaws reflect current state statutes; therefore, some hospitals in Connecticut do not grant admitting privileges.

“Little things like that are terribly irritating,” said Parisi, who suggested several possible reasons why hospitals wouldn’t allow a nurse-midwife to practice within the full scope of her license, including pressure from physicians, medical staff or the hospital legal department or, simply, resistance to change.

Nurse-midwives follow the same standards of care as OB/GYNs, but the difference in how they deliver care has an increasing number of women gravitating to the midwifery model. The Connecticut Childbirth & Women’s Center, which at its inception about 25 years ago delivered five or six births per month, now facilitates up to 35 per month and has increased its staff accordingly, from two to five full-time nurse-midwives.

Melanie Stengel photo

Midwife Lindsay Lachant lets some light into the birthing room at the Connecticut Women’s & Childbirth Center in Danbury.

One of its patients is 25-year-old Teja Brindisi, a resident of Naugatuck, who switched her healthcare provider halfway through her first of two pregnancies from an OB/GYN practice to the Connecticut Childbirth & Women’s Center. For her second child’s delivery, she had a natural water birth delivery at the center with the aid of a nurse-midwife, an experience she called “amazing.”

It was also affordable, covered by her health insurance to the same extent a hospital birth attended by an OB/GYN would have been. With rare exceptions, all insurances cover midwifery services, including HUSKY/Medicaid, though some plans reimburse midwifery services at 90 percent of the physician rate, said Stephanie Welsh, vice president of the American College of Nurse-Midwives’ Connecticut affiliate.

“We have been fighting the battle for equal reimbursement for many years, and will continue to do so,” Welsh said.

While the cost to patients is typically the same whether they use a nurse-midwife or an OB/GYN, they may feel like they’re getting a better deal with a nurse-midwife.

“By seeing only two to three patients an hour a midwife has time to spend with her client. Physicians simply do not have the time in their schedules to accommodate such lengthy visits for a low-risk woman,” Parisi said. In contrast, their midwife practice schedules only two to three patients per hour.

Physicians may spend less time with patients, but tend to apply medical interventions more readily than nurse-midwives, whose model relies less on medical interventions and more on educating and communicating with patients.

“Midwifery is a relationship-based profession. One of the reasons we probably do have better outcomes is because we listen to women,” Yale’s Kennedy said.

Despite differing perspectives, many midwives and OB/GYNs work together and report a collegial relationship.

“The physicians in my practice are very receptive to midwifery input, and really value our expertise,” said ACNM’s Welsh, who practices at Manchester Hospital with six other midwives and 14 physicians.

John Kaczmarek, an OB/GYN with privileges at St. Mary’s Hospital and Waterbury Hospital, said of nurse-midwives: “I’ve learned a lot from them; for example, we don’t always have to force nature.”

But Kaczmarek was quick to acknowledge the hierarchy within his practice. “[Nurse-midwives] practice independently but know their limitations,” he said.

“They know when to call for physician help.”

That may be true, but when it comes to compassionate care, midwives seem to know no limits. “With the midwives, I felt more taken care of,” Westchester’s DeGraf said.

No amount of fame or fortune can run interference when it comes to mothers dying or at-risk during pregnancy, childbirth, or early motherhood. And that holds especially true for African American women.

The World Health Organization defines maternal mortality as “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy” not from accidental or incidental causes. Worldwide, 99 percent of women who die during or after childbirth live in developing countries. Skilled care before, during, and after pregnancy are a proven deterrent.

In Connecticut, between 2011 and 2014, the official count for pregnancy-related deaths is 8. There are no more recent numbers, and that number is inaccurate. Maternal deaths have been woefully underreported, with scant attention paid to racial breakdowns. Connecticut was, however, included in a 2017 study that looked at 27 states and the District of Columbia. The report said that between 2013-2014, there were just over 56 maternal deaths for every 100,000 births among African American mothers, compared to just over 20 for white mothers.

iStock Photo.

In CT, the official count of pregnancy related deaths is 8 from 2011-2014. There are no more recent numbers.

Maternal deaths are tied to multiple factors, including poverty, access to health care, the health of the mother prior to pregnancy, as well as less easily-identified reasons. A recent California survey said doctors tend not to listen to African American women as carefully as they do white women. When her daughter Alexis Olympia was born last September by emergency C-section, tennis great Serena Williams had to ask twice for a CT scan. (A nurse thought the tennis great was loopy from pain medicine.) When her medical team finally listened to Williams’ suggestion, the scan revealed blood clots in her lungs. Later, her C-section burst open, and the complications nearly grounded her.

The crisis has been building, but only recently have elected officials started to take notice. Earlier this month, a bipartisan group of U.S. Senators asked the White House to commit to reducing maternal mortality. The group includes 14 senators, including Lisa Murkowski (R-Alaska); Cory Booker (D-New Jersey); and both senators from Florida, Bill Nelson, a Democrat, and Marco Rubio, a Republican. The senators asked for more data, particularly around women living in poverty who receive government aid.

Also earlier this month, after a USA Today investigation into the phenomenon, the powerful House Ways and Means Committee sent letters 15 hospitals chains, asking them for information about the deaths of new mothers in their care, as well as how they identify at-risk women, the number of deliveries they performed in 2017, and information about pregnancy-related deaths of women in their care. The hospital chains operate 900 hospitals around the country.

Add to that some private initiatives, including a grant program from Merck & Co., a pharmaceutical company that announced plans to give $500 million to city-based organizations that work to reduce maternal mortality.

Unfortunately, this program isn’t state-funded, either. In the face of this health crisis, an unfunded program feels like lip service. The next session starts in January. Let’s see if Connecticut’s legislators can take another, serious look at this. Research takes funding. Collecting data does, as well.

Susan Campbell is a distinguished lecturer at the University of New Haven. She can be reached at slcampbell417@gmail.com.

According to a lawsuit filed by her family, Gallagher was 38 and an avid skier who was dedicated to her family, which included her fiancé, Max Di Dodo. There were signs that her pregnancy was challenging. At a little over 37 weeks, Gallagher, of New Canaan, showed signs of a low platelet count. The condition, known as thrombocytopenia, affects 7 to 12 percent of pregnant women.

Gallagher also showed an elevated level of protein in her urine, known as preeclampsia, which, if left untreated, can develop into eclampsia and potentially fatal seizures.

Her twins, Thomas Walter, a boy, and Layla Maura, a girl, were born a minute apart, two and a half hours after she was admitted. Gallagher’s blood pressure kept dropping, and she was given medication—Ephedrine and Toradol, the latter of which is generally used as a pain reliever.

Maura Gallagher

Gallagher complained of a headache and nausea, and she was vomiting. Her blood pressure, according to a lawsuit filed by the family, kept fluctuating. She was given more medication, but, according to the lawsuit, she suffered a seizure, and within a few hours, a brain CT scan revealed that the new mother of two had suffered a massive intracerebral hemorrhage, when blood bursts into the brain. Gallagher was effectively brain dead with no chance for recovery. She was pronounced dead the following day.

The medical/malpractice/wrongful death lawsuit against Stamford Health, which operates Stamford Hospital, was filed in June. The family has chosen not to talk to the press, as has the hospital, where a spokeswoman said they do not comment on active litigation.

Not discussing pending litigation makes sense, but the sad fact is that no one is talking about the dramatic number of young mothers dying during pregnancy or within hours of giving birth. The most we can glean about the deaths of new mothers is from random GoFundMe pages, such as one for Lindsay Bugbee Crosby, a Simsbury mother of three who died in July just days after giving birth to a son.

Or there’s another lawsuit, filed by the family of Jessica Garofalo against Waterbury Hospital, after Garofalo’s 2016 death. She gave birth to a daughter, who died a day after her mother died.

The United States has the highest rate of pregnancy- or childbirth-related deaths in the developed world. According to United Health Foundation, in 2018 the maternal mortality rate for the country is 20.7. That’s 20.7 deaths per 100,000 births from any cause related to or aggravated by pregnancy, excluding accidents. In Connecticut, the maternal mortality rate is 13.2. The state legislature passed and Gov. Dannel P. Malloy signed a bill that creates a Maternal Mortality Review Program as part of the state Department of Public Health. You can’t fix what you don’t know, but the effort is unfunded. And there’s just one physician assigned to study the data.

Rep. Jonathan Steinberg, who represents Westport and is co-chair of the legislature’s public health committee, responded to an email asking if any one in his district—where he is running for re-election— has ever talked to him about maternal mortality.

“You’re definitely the first to bring it up,” he wrote. “It doesn’t rank in the top 10 issues in my district.”

But maybe it should. Because meanwhile, a woman giving birth in, say, West Hartford, is three times more likely to die than in Great Britain or Canada. Pregnant women and new mothers in China and Saudi Arabia have a better time of it than new mothers here.

Why can’t we do better by our women? According to one report on maternal mortality review committees, hemorrhage and cardiovascular and coronary conditions are the leading cause of maternal death, followed by cardiomyopathy, infection and embolism. The numbers vary between races, but there isn’t enough data collected to know underlying causes for Hispanic pregnancy-related deaths.

If this was any other health crisis—say, prostate cancer—would we be so comfortable being this ignorant about the whys and wherefores? A recent report from the CDC Foundation says 60 percent of these deaths are preventable. If that’s not a spur to action, how many more women do we need to lose? Connecticut legislators convene again in January.

Let’s make it our business to make this their business.

Christine Stuart of ctnewsjunkie.com contributed to this report.

Susan Campbell is a distinguished lecturer at the University of New Haven. She can be reached at slcampbell417@gmail.com.

]]>http://c-hit.org/2018/09/20/mothers-are-dying-in-childbirth-why-isnt-anyone-talking-about-it/feed/0Surge Of Women Candidates Challenges Politics As Usualhttp://c-hit.org/2018/08/21/surge-of-women-candidates-challenges-politics-as-usual/
http://c-hit.org/2018/08/21/surge-of-women-candidates-challenges-politics-as-usual/#respondTue, 21 Aug 2018 08:30:22 +0000http://c-hit.org/?p=301507Women (particularly Democrats) are running for political office in record numbers. After the recent primary elections (including one in Connecticut), voters will choose from an unprecedented number of female candidates—198 in the U.S. House, 19 in the U.S. Senate, and 13 gubernatorial candidates.

So, if a change is gonna come, it will need to include some much-needed renovations in the halls of power. Last-minute meetings make it difficult for people responsible for child care to attend. Caucuses at 2 a.m. have the same effect. If women will be political leaders, there will need to be a shift in how we do things, and what we expect of our politicians.

Mae Flexer, a state senator from the 29th District, is executive director of the Connecticut affiliate of Emerge America, which recruits and trains Democratic women to run for office. Flexer said her organization trained 33 women this year to see the political world as it is, and to plan to help change it.

One of the biggest challenges? “In terms of getting elected, women are often forced to go through more hoops to prove they’re qualified,” Flexer said. “It’s a different set of standards. Men are almost never put through the same ringer.”

For office-holders, more attention paid to scheduling and the timing of meetings would be helpful for candidates—particularly women—who are responsible for child care. Christine Palm, former spokeswoman for the Permanent Commission on the Status of Women, and the Commission on Women, Children, and Seniors, is running on the Democratic ticket for the 36th House District.

“At the state level, there needs to be some regulation of hours during session or a daycare/sleepover capacity for kids,” Palm said. “There’s a reason a lot of women our age enter politics when we do; no one at home who needs me.”

In the recent primary, Jillian Gilchrest, who bested a 12-term incumbent for the Connecticut 18th House District, said political parties need to be willing to open the door for new leaders.

“If we’re going to support female candidates, we need to shift the way we look at incumbency,” Gilchrest said. “Long-standing politicians should be encouraged to continue on within the party in another role, but need to recognize the importance of supporting female candidates.”

This year of female candidates is astounding. One of the most talked-about upsets came from Jahana Hayes, 2016’s National Teacher of the Year, who grew up in public housing, the daughter of an addict. Hayes started her campaign to represent the state’s 5th Congressional District just 102 days before the primary election with, she says, “no money, no network, no people.”

Improbably she won, defeating a far more seasoned and connected politician.

Here’s something else improbable: Her opponent was a woman—Mary Glassman, the party’s endorsed candidate and former first selectwoman of Simsbury.

The New York Times called the primary election “groundbreaking.” That’s exciting. Now we must go about moving some walls and making way for more women.

Susan Campbell is a distinguished lecturer at the University of New Haven. She can be reached at slcampbell417@gmail.com.

]]>http://c-hit.org/2018/08/21/surge-of-women-candidates-challenges-politics-as-usual/feed/0Strategic Outreach Bridging Racial Gap In Pregnancy-Related Health Outcomeshttp://c-hit.org/2018/08/07/strategic-outreach-bridging-racial-gap-in-pregnancy-related-health-outcomes/
http://c-hit.org/2018/08/07/strategic-outreach-bridging-racial-gap-in-pregnancy-related-health-outcomes/#respondWed, 08 Aug 2018 01:02:54 +0000http://c-hit.org/?p=295143New Haven resident Kimberly Streater was pregnant with her third of six children when she called her friend for a ride to the hospital after sustaining a hit to her stomach by her then-husband.

When she reached the hospital, Streater, not yet 28 weeks pregnant, alerted personnel that her baby was coming—now. “They said, ‘No, no, he’s not coming,’ after I told them he was,” she recalled. Minutes later, Howie was born at 3 pounds and 1.5 ounces in the admitting area of the hospital, just as Streater had predicted.

Statistically, the preterm birth of Streater’s baby does not come as a surprise. In Connecticut and nationwide, black women and their infants suffer disproportionately worse pregnancy-related health outcomes than white women.

Carl Jordan Castro Photo

Kimberly Streater with her son Howard Lewis, 18, in her office in New Haven.

The March of Dimes’ 2017 Premature Birth Report Card for Connecticut revealed that between 2013 and 2015, 8.4 percent of all (live birth) infants born to white women were premature, compared with 12.4 percent of infants born to black women. Statewide, after a complication-free delivery, black women are twice as likely as white women to be readmitted to a hospital within 30 days, according to a 2015 study published in the journal Obstetrics and Gynecology, which drew from statistics maintained by the Connecticut Department of Public Health.

These racially disparate outcomes mirror persistent racial gaps nationwide. Babies born to black women are more than twice as likely to die in the first year of life than babies born to white women, and black women are 243 percent more likely than white women to die from pregnancy-related complications, according to the Centers for Disease Control and Prevention.

These statistics aren’t new. What’s new is how some professionals throughout Connecticut—from psychiatric researchers to community activists to medical doctors and progressive health centers—are reframing the way racial disparities are addressed: by re-examining their root causes and coming up with new solutions. This close examination of racial disparities in pregnancy-related outcomes coincides with a recent push to address the nation’s discouraging overall maternal death rates, which increased by more than 25 percent between 2000 and 2014, while those in other developed countries declined, according to a study published in the journal Obstetrics and Gynecology.

New Haven Healthy Start (NHHS), a community-based program, has been working for three decades to identify and eliminate racial disparities in birth outcomes. The organization has examined several factors as possible culprits in the racial divide, including poverty, health insurance, and access to prenatal care. Ultimately, they homed in on one factor.

“Racism. Discriminatory practices based on race. That’s what we’ve been focusing on,” said Kenn Harris, president of the board of directors of the National Healthy Start Association and project director at NHHS. In response, they offer a program where women, regardless of their race, feel truly supported throughout their pregnancy.

Meeting Moms Where They Are

At the heart of NHHS’s simple yet highly effective strategy is its care coordination service model, recruited from places including libraries, laundromats and beauty salons within the communities they serve. They do outreach at strategically located places where pregnant women in the program’s target population are likely to visit, including community health centers and homeless agencies. Every participant is assigned a care coordinator, who provides an array of support—from helping them sign up for state Medicaid to arranging transportation and childcare to reaching out to them if they miss a doctor appointment.

The key to these care coordinators and other employees at NHHS? They look like the women they serve, and, in many cases, they’ve been through similar situations. Natasha Ray, a 49-year-old resident of East Haven, had her first of four children at 16; all her infants were born premature. Now she’s the core service manager at NHHS.

“My interest in the program was personal. Here was a program whose focus is on prematurity, health disparities and strengthening the fragmented system that families must navigate. I feel that this was an opportunity to be the person for so many mothers-to-be that I did not have. When you know better, chances are you will do better,” Ray said.

The approach works. In 1987, one in every 50 infants born in New Haven died in the first year of life. Today, only one out of every 222 infants whose mothers are enrolled in NHHS dies in the first year of life, according to the Community Foundation for Greater New Haven, which runs the Healthy Start program in New Haven. In 2017, 1,402 women were enrolled in NHHS. Of these, 43 percent were black, 38.5 percent were mixed race, 16 percent white, and 2.5 percent Asian.

Another program making a difference in the health of black moms is The New Haven MotherS (MOMS) Partnership. This community–academic partnership, founded in 2011 by Yale associate professor of psychiatry Megan Smith, DrPH, MPH, seeks to improve maternal mental health among low-income women through a community-driven approach.

“We know that depression co-occurs with trauma and anxiety disorders, particularly post-traumatic stress disorders, and that they can increase a woman’s chance of preterm birth,” said Smith, who is also the program’s director.

Smith said she started the MOMS partnership because of increasing racial inequities she observed related to mental health care among New Haven residents. “They’re more likely to drop out of mental health care programs, and less likely to receive high quality mental health care,” Smith said of the women targeted by the MOMS partnership. Since its inception, the program has reached more than 500 low-income moms and pregnant women from New Haven, about 70 percent of whom are women of color.

The program provides outreach to mothers and pregnant women in targeted neighborhoods of New Haven, requesting that they complete mental health assessments. Those who demonstrate need receive cognitive behavioral therapy in familiar settings, including the second floor of the city’s Stop & Shop grocery store and other citywide locations. The treatment setting is non-threatening; so too are the community mental health ambassadors (CMHAs), employees who recruit participants and accompany them to treatment.

CMHAs are mothers from the local community trained to focus on target population outreach and, when deemed necessary, to support mental health treatment. They work alongside traditional mental health clinicians. Most possess customer service experience; they all empathize with the participants’ struggles.

Smith attributes the program’s overwhelming success largely to the ambassadors and the community settings where they serve women. To date, over 70 percent of participants registered for cognitive behavioral therapy through the partnership have adhered to treatment, and more than 50 percent report decreased depressive symptoms.

Carl Jordan Castro Photo

Kimberly Streater with her youngest daughter Nevaeh Lewis, 14, and son Howard Lewis.

Streater, who gave birth prematurely to two of her six children, is a CMHA. She learned about the job when taking a free stress management class about five years ago. Streater says she didn’t have much of a support network as a pregnant or new mom. “It was pretty much me,” she said.

Implementing simple, common-sense practices within existing healthcare systems also lends support that can help close racial gaps in pregnancy outcomes. At Southwest Community Health Center in Bridgeport, about 80 percent of the patients that advanced practice midwife Janet Spinner sees are women of color. She’s pleased about the decisions the center makes to accommodate its patient population’s health needs. For instance, instead of waiting to see patients at the typical six-week postnatal visit, Spinner has new mothers come for a checkup between one and two weeks after delivery, then again at the six-week mark. “That’s when scary post-pre-eclampsia can rear its ugly head,” Spinner said of the dangerous medical condition that occurs more frequently among black women and can happen during or shortly after pregnancy. Spinner also uses the initial postnatal visit to check in with patients about breastfeeding, social support, and intimate partner violence, which she refers to as “the elephant in the room.” And, Spinner says, the Bridgeport health center provides strong diversity training to its employees, a trend she sees becoming more prevalent throughout the state.

“We really need to talk about this as a community,” she said.

Black women might be more likely to go to the doctor’s office when the doctor looks like them. Marcia Tejeda, MD, a black OB/GYN who works in Waterbury, acknowledges that she probably sees 5 to 7 percent more black patients than the other physicians in her group practice—a choice based on her patients’ preferences.

Although Tejeda says she feels all the physicians with whom she works make a “tremendous effort to give all women excellent care,” she does suggest that, in general, doctors and other medical professionals could benefit from education and training that focuses on how to improve their interactions with black patients, including learning how to better understand their culture and improve ways of communicating with them. Tejeda also proposes that race-specific research initiatives occur more routinely.

“Now that we see the mortality rate is higher for black women, we need to do research that’s specially geared toward black women,” Tejeda said. “That will be the key to decreasing mortality for black women and improving outcomes for their babies.”

Your guess is as good as our government’s. We simply don’t know. Even the statistics we have aren’t current, though from all indications the U.S.’s mortality rate is rising, as it is in Afghanistan and Sudan.

But in the U.S., the rate has risen by 136 percent between 1990 and 2013.

The Centers for Disease Control and Prevention (CDC) recognized gaps in the data all the way back in 1986, during the Reagan administration. Since then, the CDC has requested that states share the death certificates of every woman who died during pregnancy or within a year of giving birth.

But it wasn’t until 2017 that all states allowed a check box on their death certificates to mark pregnancy-related deaths. The CDC reports significant disparity among races, with a far higher figure for African American mothers (43.5 deaths per 100,000 live births, compared to 12.7 deaths among white mothers). According to a 2014 study from, among other organizations, the National Latina Institute for Reproductive Health, in some parts of Mississippi the rate of maternal death for women of color exceeds that of sub-Saharan Africa.

iStock Photo.

In CT, between 2011-2014 eight women died within a year of delivering a baby. No other data is available.

The most frequent cause of death (at 15.5 percent of all maternal deaths) was cardiovascular disease. Other causes include preeclampsia, a complication that can include high blood pressure and damage to organs such as the liver and kidneys. Doctors say that at least half of these deaths are preventable.

In Canada, the rate is 7.3 maternal deaths per 100,000 live births. In Western Europe—Italy, Norway, Sweden—the number is 7.2. Since the United Nations set a goal in the ’90s to reduce maternal mortality by 75 percent, the universal maternal mortality ratio was cut by 45 percent by 2013. But not in the U.S.

In addition to the deaths of mothers, according to a 2017 Quartz report, another 50,000 U.S. women narrowly escape death during pregnancy or childbirth, and every year, another 100,000 women become seriously ill during or after a pregnancy. Here’s another perspective: A joint NPR/ProPublica report said that for every woman who dies from childbirth, 70 more come close.

In a time of big data, how is this an area where we fall tragically short? Data isn’t everything, but without knowing the issue, there’s no chance we can address it.

Compiling data takes time and it takes money. So how does a review of the roots of maternal mortality happen without (current) data? And how does data get collected without funding? Go to United Health Foundation’s America’s Health Rankings and try to find current data on Connecticut’s maternal mortality rate. It’s sparse.

This work is too important to hand to doctors to try to work that into their already-busy schedules. A high maternal mortality rate is a blight on the nation and the state. It’s possible to share maternal mortality data and still protect all-important patient confidentiality. This important work needs more than lip service. It needs funding, and dedicated personnel.

]]>http://c-hit.org/2018/07/10/maternal-deaths-rising-at-alarming-rate-but-whos-counting/feed/0Poor And Minority Women Face Widening Barriers To Depression Treatmenthttp://c-hit.org/2018/07/02/poor-and-minority-women-face-widening-barriers-to-depression-treatment/
http://c-hit.org/2018/07/02/poor-and-minority-women-face-widening-barriers-to-depression-treatment/#respondMon, 02 Jul 2018 12:15:38 +0000http://c-hit.org/?p=280876Among women, those who are low-income or minority are less likely to get treatment for depression, according to multiple studies.

A report by the Connecticut Behavioral Health Partnership found that women were underrepresented in Medicaid-funded behavioral health services in the state even though research shows that women suffer from the most commonly diagnosed mental health disorders more frequently than men.

Racial and ethnic disparities, while still considerable, are decreasing in some physical illnesses. “But in mental health care, in the last 10 years, we see those disparities widening,” said Megan Smith, associate professor in the Departments of Psychiatry and in the Child Study Center in the Yale School of Medicine, who runs the Mental health Outreach for MotherS (MOMS) Partnership®, a program that offers mental health services to “overburdened and under-resourced mothers.”

In this podcast, sponsored by ConnectiCare, Colleen Shaddox discusses the hurdles to mental health care and the programs breaking barriers to care with Yale’s Megan Smith and UConn Health’s Dr. Sarah Nguyen.

Lack of insurance coverage, the cost of treatment, a shortage of qualified clinicians, stigma and even fear of losing custody of their children can keep women from seeking help, Smith said. Blacks and Hispanics are more likely to report psychological distress than non-Hispanic whites, and the rates increase dramatically for minorities who live in poverty, according to the Centers for Disease Control and Prevention. But white women are using mental health services at more than twice the rate of black or Hispanic women, data from the federal Substance Abuse and Mental Health Services Administration show.

“Unfortunately, lack of health insurance is often the biggest barrier to receiving care for depression. And with the lack of insurance there are financial barriers that come into play,” said Dr. Sarah Nguyen, a psychiatrist and faculty member at the University of Connecticut School of Medicine.

Yale School of Medicine Photo.

Megan Smith, associate professor in the Departments of Psychiatry and Child Study Center, Yale School of Medicine.

More than 42 percent of adults who do not get needed mental health treatment said they cannot afford it, according to the National Survey on Drug Use and Health. Medicaid does not reimburse clinicians for the full cost of mental health treatment, creating a shortage of providers who accept Medicaid. A 2015 study found that Connecticut clinicians experience a $27 million annual loss versus standard fees when providing mental health care under Medicaid.

There is also a shortage of clinicians who are minorities. “I think it goes back to increasing the human capital in the mental health field,” Smith said. “What I mean by that is really increasing the training and the availability of providers who are of racial and ethnic minority background themselves, and of providers who accept Medicaid and sliding scale, and, particularly, providers who are using evidence-based treatments. We know we have to be concerned about the quality of care, and so we want to, of course, lift up the quality of care that everyone receives.”

And then there is stigma, which is blamed for keeping people out of treatment regardless of background. Research shows that pressure to be “a strong woman” and a reliance on faith communities and other sources outside of health care providers discourage black women from seeking depression treatment.

Women who use the MOMs program often do not even use the word depression. “Stress is actually the way that many mothers we talk to describe depression,” Smith said. “So, mothers will talk about stress and really mean anxiety, trauma, addiction, depression.”

Women can access MOMs services at places like the laundromat. They can even get therapy at the local Stop & Shop. “The feedback we have from mothers on that is excellent,” Smith said. “They really like receiving care there. They feel safe. They feel secure, and it really feels like part of the community.”

One day a week Nguyen practices in a primary care center and sees patients she says would never have come to her psychiatry office to begin therapy. “Once I’ve established a rapport and a relationship with [patients] they’re more open to seeing me in other clinics,” she said.

Being in the primary care clinic is a particularly good way to get immigrant women into treatment, Nguyen added, because immigrants with depression are more likely to come in complaining of a physical problem like a stomach ache.

Tina Encarnacion/UConn Health Photo.

Dr. Sarah Nguyen, a psychiatrist at UConn Health.

Fear surrounding immigration status keeps some people from seeking depression treatment and so does fear of losing custody of a child. Smith stressed that mothers around the country do face child welfare systems that can penalize them for mental illness, but she offered assurances that Connecticut is different. “I think what’s helpful in Connecticut is that our child welfare system is informed about brain science and child development and knows the importance of promoting that dyadic relationship between mothers and children,” she said.

Though financial barriers can keep women out of care, Dr. F. Carl Mueller, associate chair of psychiatry at Stamford Health, urges women not to assume that care is out of reach. “There’s a lot you can do,” he said. “This is not necessarily an expensive proposition. There are short-term treatments that get people out of the darkest places.” He added that treating depression can be essential to avoid lost wages and even job loss. “Depression kills income,” he said.

There is a 50 percent increase in employment among women who get mental health treatment through MOMs, Smith said, citing “a real link between mental health and wealth.”

This is Part 2 of C-HIT’s series on women and depression, sponsored by ConnectiCare.Part 1 is available here.

In 2016, the most recent year for which state-level data is available, Connecticut had 53.4 births per 1,000 women ages 15 to 44, compared with a national average of 62 per 1,000 women, according to data from the Centers for Disease Control and Prevention (CDC).

Just four states had lower rates than Connecticut in 2016, and all are in New England: Vermont at 50.3 births per 1,000 women, New Hampshire at 50.9, Rhode Island at 51.8 and Massachusetts at 51.9.

The states with the highest fertility rates in 2016 were South Dakota at 77.7, North Dakota at 77.3, Utah at 76.2 and Alaska at 76.1, the CDC reports. Unlike birth rates, which take an entire population into account, fertility rates reflect the share of babies born to women of childbearing age.

iStock Photo.

The state has seen an increase in women over 30 having babies.

Connecticut typically ranks low on the list, along with other “high achievement, high education states,” said Dr. Harold J. Sauer, chairman of obstetrics and gynecology at Yale New Haven Health’s Bridgeport Hospital. Higher education levels correlate with lower fertility rates, he added.

“People who are well educated [in general] are also well educated about their reproductive options,” said Sauer, who is a clinical professor in Yale School of Medicine’s Department of Obstetrics, Gynecology and Reproductive Sciences.

Women are increasingly aware of birth control methods and other options that allow them to control many aspects of reproduction, and more are seizing the opportunity, he said.

In 2014, the average age of first-time mothers in Connecticut was at or near 28, compared with the national average of 26.3 years, the CDC reports. Between 2000 and 2014, the nationwide average age of first-time mothers rose from 24.9 years old to 26.3 years old, data show, and the increase was most pronounced from 2009 to 2014.

Provisional fertility rate data from the CDC show the national average fell another 2 percent in 2017, to a new record low of 60.2. State-level 2017 data isn’t yet available. There were 3.853 million births, the lowest in 30 years, the CDC reports.

The provisional number of births last year declined 2 percent for Hispanics, 3 percent for whites and was unchanged for blacks.

Like the nation overall, Connecticut has seen a drop in teenage mothers giving birth. At the same time, the state has had an increase in women in the 30-to-49 age group having babies, said Dr. Amanda Kallen, assistant professor of Obstetrics, Gynecology and Reproductive Sciences at Yale School of Medicine.

“We’re significantly lower [than the national average] in the 15-19 age group, which is great,” said Kallen, who specializes in pediatric and adolescent gynecology at Yale.

In 2016 in Connecticut, there were 9.4 births per 1,000 teenage girls ages 15 to 19, according to data from the U.S. Department of Health and Human Services’ Office of Adolescent Health—well below the national average of 20.3 per 1,000 women. Only Massachusetts and New Hampshire had lower rates, at 8.5 and 9.3 per 1,000 women, respectively.

“We’re seeing a skew in births in Connecticut more toward the over-30 age group,” Kallen said. “We’re definitely seeing this sort of delayed childbirth phenomenon. Marriage is taking place later, if it’s taking place at all. Women in Connecticut are having babies. There’s just a trend towards later.”

Women who wait until they are older to have children, Sauer said, may have a harder time getting pregnant or carrying a pregnancy to term. A woman’s egg quality and number decline with age, especially after age 35, he added.

Some women opt to freeze their eggs but there’s no guarantee that all frozen eggs will produce viable embryos, Kallen said.

“You’re born with all the eggs that you’ll ever have. When that pool of eggs is gone, the chances for pregnancy are also gone,” she said. “You are more likely to have success if you start earlier and you’re more likely to have difficulty if you start later.”

Cara Rosner was interviewed by Ray Dunaway on WTIC. Listen to her interview here.

]]>http://c-hit.org/2018/06/27/connecticut-fertility-trends-older-mothers-and-fewer-babies/feed/0Depression Affects Women At Twice The Rate As Menhttp://c-hit.org/2018/06/19/depression-affects-women-at-twice-the-rate-as-men/
http://c-hit.org/2018/06/19/depression-affects-women-at-twice-the-rate-as-men/#respondWed, 20 Jun 2018 01:51:12 +0000http://c-hit.org/?p=274831Depression is the leading cause of disability worldwide, according to the World Health Organization, and affects women at about twice the rate that it does men.

In Connecticut, 21.4 percent of women report experiencing depression, compared with 13.4 percent of men, according to 2015 Department of Public Health data.

Millennial women in the state experience depression four more days in an average month than their male counterparts, the Status of Women data project reported this year.

Women are more likely to use mental health services than men, but studies consistently show that the majority of Americans with depression go untreated.

Though the stigma around mental illness has lessened, experts say that it still keeps women from getting help. “I think we’ve made some inroads in that regard, but I think that still exists. It’s very important for people to understand that this is not a failure, this is really a biological illness, and that if you’re having symptoms, it’s really important to get help,” said Carolyn Mazure, director of Women’s Health Research at Yale.

Robert Lisak Photo.

Carolyn Mazure, head of Women’s Health Research, Yale School of Medicine.

Women are prone to depression, often triggered by hormones, such as during the post-partum period, but research suggests that women have a different biological response to stress throughout their lives that contributes to higher rates of depression, according to Mazure.

Biology is not the whole story. Mazure pointed out that women on average have less money and more caregiving responsibilities than men.

Dr. Carl Mueller, associate chief of psychiatry at Stamford Hospital, said that in the workplace women often have “responsibility without authority,” a stressful, no-win situation.

Girls and women are also sexually abused at higher rates. More women are coming in for treatment as the #MeToo movement brings up old trauma, Mueller said. “It is empowering,” he said. “People would like to address those issues that sometimes have tormented them for years.”

Connecticut author Luanne Rice, who writes about her depression, recalled how the stigma made it difficult to get help. She missed a lot of school growing up in the 1960s. “I couldn’t say, ‘I feel down. I feel depressed,’” she said. “Nobody used that word back then. Or if they did, it wasn’t in my family.”

Rice said she was sexually abused as a child by a trusted adult. She was also burdened by a precocious sense of responsibility for keeping her family together, though her beloved father’s alcoholism put enormous strain on her parents’ marriage. Finally, a teacher at her high school saw that Rice was depressed and urged her family to get her counseling. “They were aghast,” Rice remembered. “They were ashamed. They didn’t know that this could ever happen to their child and they said, ‘Well you can see a counselor as long as you don’t talk about the family.’”

Another significant factor in women’s depression is “rumination.” Research shows that women are more likely to turn problems over in their minds repeatedly. This can worsen depression. One of the goals of therapy is often to replace rumination with other coping skills—to change the tape that is playing inside the patient’s head. In addition to cognitive strategies, medication is a common treatment. The most popularly prescribed class of antidepressants, SSRIs, have been shown to be more effective in women than in men.

Kristina Loggia Photo.

Best-selling author Luanne Rice.

Rates of depression in the country are rising, particularly among adolescents and seniors, noted Dr. Sarah Ngyuen, an assistant clinical professor at the University of Connecticut School of Medicine, but rates of treatment are not. She said a large volume of research shows that financial barriers play a big role in keeping people out of treatment. But like other medical professional interviewed, she believes that stigma also stops people from getting help.

“I’m the assistant women’s golf team coach for Yale University. So, I get to interact on a weekly basis with very lovely, ambitious, athletic student athletes,” Nguyen said.

“And I do see that in talking about barriers and stigma, even though Yale is a pretty open community and this is well talked about, it’s still somewhat stigmatized. And I see the shame and embarrassment sometimes that is carried with having depressive symptoms or anxiety. And there is this mentality of what I’d like to term destructive perfectionism, where I think the society and culture that we live in kind of fosters heightened anxiety and depression as a result,” Nguyen said.

The main character of Rice’s latest young adult novel, The Beautiful Lost, is Maia a teenager with depression. The book has an afterword, where Rice shares her own story and encourages readers who have depression to get help.

“That’s a big first step…to be able to reach out and talk to someone,” she said.

Psychologist Carolyn Mazure Says When Sadness Doesn’t Go Away

•Don’t try to hide it. Talk with someone you trust about how you feel.

•You may not click with your first therapist. Your first medication may not help. That’s OK. There are lots of options. Keep looking until you find the one that works for you.

]]>http://c-hit.org/2018/06/19/depression-affects-women-at-twice-the-rate-as-men/feed/0Connecticut Takes Small Step Toward Supporting Maternal Mortality Reviewhttp://c-hit.org/2018/06/14/connecticut-takes-small-step-toward-support-maternal-mortality-review/
http://c-hit.org/2018/06/14/connecticut-takes-small-step-toward-support-maternal-mortality-review/#respondThu, 14 Jun 2018 11:43:23 +0000http://c-hit.org/?p=273302The Centers for Disease Control and Prevention (CDC) found that 700 women in the United States die each year as a result of pregnancy or pregnancy-related complications, and the rate has more than doubled since 1987. Pregnancy-related deaths per 100,000 live births rose from 7.2 nationally in 1987 to 17.3 in 2013, peaking at 17.8 in 2009 and 2011.

In Connecticut, there were eight pregnancy-related deaths from 2011 to 2014. But there’s no data available yet for the years since 2014 and at the moment there are precious few dollars devoted to accessing it

For more on this story by Christine Stuart of ctnewsjunkie.com click here.